Anal Fissure Therapy

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Dear OncoLink "Ask The Experts," Two years ago I had cancer of the anus and was treated with chemo and radiation but I am still having symptoms. My physician says it is a fissure, but the symptoms are like the cancer had been. I have stool with blood and a burning pain -- can a fissure do this?

Najjia N. Mahmoud, MD, Assistant Professor of Surgery at the Hospital of the University of Pennsylvania in the Division of Colon and Rectal Surgery, responds:

A fissure can indeed do this, but this is a somewhat complicated situation. First of all, you have to be absolutely sure it is not recurrent cancer. That means that the area must be examined inside and outside -- if this is too painful in the office, typically an exam under anesthesia is warranted.

A fissure is a split or break (like a cut) in the anal mucosa (lining). It can persist, be very painful, and bleed. Typical symptoms include severe pain and bleeding with bowel movements. Fissures are usually caused by either persistent diarrhea or hard, constipated stools.

Fissures can be categorized by the length of time that they are present. Fissures that are present for less than 6 months are commonly called "acute" fissures, and they respond to various conservative treatment regimens a bit better. Fissures that are present for greater than 6 months are called "chronic" fissures, and they more difficult to manage.

Fiber therapy (1 tbsp of insoluble fiber product in 8-16 oz water or juice/day) works to cure 80% of acute fissures in 6-8 weeks. The results are less favorable for chronic fissures. Nitroglycerin ointment (.2%) is another commonly prescribed treatment for fissures that has been effective in clinical trials. In Europe, calcium channel blockers in an ointment form have also worked well. There is some evidence that Botox injections into the internal anal sphincter can work, too. The "gold standard" of fissure therapy, by which all other treatments are measured, is the lateral internal sphincterotomy. This is an outpatient surgical procedure that involves making a very tiny incision in the internal sphincter to divide 1/4 to 1/3 of the fibers, thus decreasing the internal sphincter pressures and allowing greater blood flow to the fissure itself. This works about 90% of the time and takes about 2 weeks.

Your history of radiation makes this a somewhat more difficult situation. Radiation makes wounds heal more slowly, and radiated tissues are more delicate and less vascular, making them more prone to damage. Operating in this setting is NOT ideal. Not only would there be difficulty healing the fissure, but there may be problems healing the wound itself. Neither would I recommend the so-called "anal stretching" procedure that is popular in some places -- this procedure has been abandoned due to a high rate of fecal incontinence and uncontrolled damage to the sphincter muscle.

In the end, once recurrent cancer has been ruled out, conservative therapy with fiber and Nitroglycerine is probably a good first start. Prompt evaluation by a colorectal surgeon would also be warranted in this case, given its complexity.